Provider Demographics
NPI:1366763260
Name:POUDRE VALLEY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:POUDRE VALLEY MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:970-624-4443
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:970-624-4420
Mailing Address - Fax:970-624-4459
Practice Address - Street 1:2695 ROCKY MOUNTAIN AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8702
Practice Address - Country:US
Practice Address - Phone:970-624-4420
Practice Address - Fax:970-624-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY130638300Medicaid
WY53D0519664OtherCLIA PVMG CHEYENNE MEDICAL SPECIALISTS
CO69906874Medicaid
NE10025926100Medicaid
AZ674844Medicaid
WY130638300Medicaid